Bess Coaches Wellness Audit for:
Full Name
*
Email
*
Height
*
Current Weight
*
Date of birth
*
Do you have any medical conditions you wish to disclose? (I.E. diabetes, hypothyroid, high cholesterol, etc)
*
Can you describe your familiarity with menopause?
*
Are you currently experiencing any bothersome symptoms of menopause?
*
Yes
No
Not sure
Goal Review Section
Which of the following best describes your goal with your fitness and nutrition?
*
I'd like to feel more confident in my own skin.
I'd like my clothes to fit better.
I'd like to build muscle and get stronger.
I'd like to be healthy and live longer.
I'd like to heal and improve my relationship with food.
What do you think is the biggest obstacle or frustration that is keeping you from reaching that goal?
*
How long has this goal felt unattainable?
*
What would it mean for you to solve this problem?
*
How much progress are you making with your current fitness and nutrition plan?
*
I don't have a plan right now.
It's very slow and frustrating.
Some progress but room for improvements.
Have you done any fad diets/what have you tried in the past?
*
Are you familiar with tracking macros?
*
Yes
No
Not sure
How many calories on average are you eating per day?(if not tracking, provide a rough estimate)
*
How would you rate your protein intake?
*
1: Barely eating protein
2
3
4
5
6
7
8
9
10: Eating close to, at or above 1g of protein per pound of body weight (or protein with 2-3 meals/day)
No elements found. Consider changing the search query.
List is empty.
How would you rate your food quality?
*
1: Not paying any attention to what I am eating - poor food quality
2
3
4
5
6
7
8
9
10: Eating green veggies at a minimum of 2 meals per day/80% whole foods
No elements found. Consider changing the search query.
List is empty.
Do you find yourself consuming large amounts of coffee or energy drinks to get through the day?
*
How would you rate your daily energy levels?
*
1: Very low energy
2
3
4
5
6
7
8
9
10: Very high energy
No elements found. Consider changing the search query.
List is empty.
How would you rate your daily stress levels?
*
1: No stress at all
2
3
4
5
6
7
8
9
10: Very high levels of stress
No elements found. Consider changing the search query.
List is empty.
Do you find that you are able to cope with and manage your day to day stress?
*
If you answered yes to the previous question, how do you cope with day to day stress (ex. walks alone, meditation, reading, watching TV)
*
On average, how many hours of sleep do you get each night?
*
6 or less hours
7 or less hours of sleep per night
7-9 hours of sleep per night
No elements found. Consider changing the search query.
List is empty.
How would you rate the quality of your sleep?
*
1:Wake up several times a night/wake up tired
2
3
4
5
6
7
8
9
10: Sleep like a rock/Very high energy upon waking
No elements found. Consider changing the search query.
List is empty.
Do you have a sleep routine (I.e. go to bed and wake up at generally the same time each day)
*
How active are you?
*
Very sedentary (no exercise routine/desk job)
Sedentary (no exercise routine/minimally active during the day)
Moderately active (exercise 1-2 days per week/about 5k steps a day)
Active (consistent exercise 2-3 days per week/active throughout the day)
Highly active (physically demanding job/consistent exercise or consistent exercise 4-5 days per week and 8-10k steps/day)
No elements found. Consider changing the search query.
List is empty.
Do you work an active job or sedentary job?
*
Active
Sedentary
It depends on the day
How do you manage your time?
*
Have you ever worked with a coach for fitness or nutrition?
*
Yes
No
If you answered yes to the previous question, can you describe what that experience was like for you?
*
Is there anything else you'd like me to know?
*